MEDICARE: JANET KAY LOGAN CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	RN189571 NP	GA

General Provider Information

NPI Number	:	1235127135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANET KAY LOGAN CPNP

Provider Business Mailing Address
First Line	:	131 HENSON RD
Second Line	:
City	:	HAWKINSVILLE
State	:	GA
Zip	:	31036-9628
Country	:	US
Telephone Number	:	478-955-8832
Fax Number	:

Provider Business Practice Location Address
First Line	:	803 MLK DRIVE
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-2227
Country	:	US
Telephone Number	:	478-827-0710
Fax Number	:	478-827-0677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	10/10/2011

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